The Social Integration of the Mentally Ill in Quebec Prior to the

Transcription

07_cbmh29.1_thifault_perreault_a.qxd 09/04/2012 2:19 PM Page 125
The Social Integration of the Mentally
Ill in Quebec Prior to the Bédard
Report of 1962
MARIE-CLAUDE THIFAULT
ISABELLE PERREAULT
Abstract. This article on the first initiatives of social integration of the mentally ill, using the example of Saint-Jean-de-Dieu Hospital, explores the implementation of dehopsitalization (the transition between hospital and community
care) in the early decades of the 20th century. Our study is part of the recent historiographical stream that offers a reinterpretation of the period just prior to the
Quiet Revolution in Quebec. We aim to contribute to this research by showing
that the policies, strategies, and practices of the Sisters of Providence and the
psychiatrists of Saint-Jean-de-Dieu already comprised a deinstitutionalization
system that was reintegrating patients into their families as early as the 1910s—
half a century before the first wave of deinstitutionalization of the 1960s was
orchestrated by the authors of the Bédard Report.
Keywords. Saint Jean de Dieu hospital, Sisters of Providence, dehospitalization,
Bédard Report
Résumé. Cet article sur les premières initiatives d’intégration sociale des
malades mentaux, en prenant l’exemple de l’Hôpital Saint-Jean-de-Dieu, présente la mise en place d’une phase de désinstitutionnalisation au cours des
premières décennies du XXe siècle. Notre étude s’inscrit dans le courant historiographique récent qui propose une relecture de la période pré-Révolution
tranquille au Québec. Nous entendons y contribuer en démontrant qu’avec
les politiques, les stratégies et les pratiques des Sœurs de la Providence et des
psychiatres un système de déhospitalisation (transition entre l’hôpital et les
soins communautaires) et de réintégration des patients dans leur famille a été
mis en place dès les années 1910, soit un demi-siècle avant que ne s’amorce la
Marie-Claude Thifault, associate professor, School of Nursing, Faculty of Health Sciences,
University of Ottawa.
Isabelle Perreault, postdoctoral fellow, School of Nursing, Faculty of Health Sciences,
University of Ottawa.
CBMH/BCHM / Volume 29:1 2012 / p. 125-150
126
MARIE - CLAUDE THIFAULT AND ISABELLE PERREAULT
première vague de désinstitutionnalisation des années 1960 orchestrée par les
auteurs du rapport Bédard.
Mots-clés. Hôpital Saint-Jean-de-Dieu, Sœurs de la Providence, déhospitalisation, Rapport Bédard
Mon cher monsieur,
En réponse à votre lettre en date du 8 Juillet courant [1909]. je regrette de
vous informer que je ne pourrai pas permettre de retirer votre femme de l’asile,
sous congé d’essaie parce que son état mental ne justifie pas cette mesure.
Votre dévoué.
Sur. Méd.1
Letters of this kind regarding requests for temporary leaves became
increasingly common in the medical files of patients hospitalized at
Saint-Jean-de-Dieu Hospital in the first decade of the 20th century, and
even more so towards the middle of the century. This study, conducted
within the framework of the project Le champ francophone de la désinstitutionnalisation en santé mentale,2 (Mental Health Deinstitutionalization in
French Canada) explores the practice of granting temporary leaves in
order to better understand the early attempts at social reintegration of
the patients hospitalized at Saint-Jean-de-Dieu. As noted, these practices had already been well underway before the first wave of deinstitutionalization of the 1960s.3
Our research into the medical files of Saint-Jean-de-Dieu Hospital
from the first decades of the 20th century reveals that of all patients
admitted in 1890, barely 1% were granted a temporary leave. By 1906,
that number had already risen to 30%, and by 1928, to over 50%.4 This
practice of encouraging the return of patients to their families went
counter to 19th-century therapeutic principles, which advocated the
confinement of the mentally ill upon the first manifestation of “insane”
behaviour, and which viewed it as problematic to immerse patients back
into the same living environment where the mental illness was believed
to have originated. The transition in the early 20th century to granting
temporary leaves can be explained as a response to the desire of the
families to see their sick relatives return home, to new theories that mental diseases were based on heredity and constitution, and to the state of
overpopulation in asylum institutions.
The economic hardship suffered by these institutions also played an
important role in the release of some mentally ill patients from asylums,
as manifested in Section 4152 of the Loi sur les Asiles d’aliénés of 1909,
which allowed the Secretary of the Province of Quebec or the medical
superintendent to mandate that chronically ill patients be sent back to
their families under the condition that they were not a cause of scandal
or danger. This procedure freed up space in the asylums that were at the
The Social Integration of the Mentally Ill in Quebec
127
time becoming increasingly overcrowded. The patients released in this
context were mainly those considered to be “idiots,” the incurably
insane, and those suffering from dementia and senility—in short, the
asylum population for whom psychiatrists had given up all hope of
recovery. Patients’ families thereby played a vital role in freeing up space
in overcrowded psychiatric institutions and in reintegrating the mentally
ill back into the community.
Our main research questions are: What was the role of the families in
the social reintegration of the mentally ill from the 1910s on? How did the
community receive these patients? And were the mentally ill actually
able to regain a place within society? Growing asylum populations,
changing beliefs about the etiology and treatment of mental diseases,
and dynamic relations between asylum authorities and the government
determined the laws and policies concerning admissions and discharges.
We begin by providing a comprehensive overview of the state of asylums
of the time, followed by a description of temporary leaves. Our study
shows that the practice of granting temporary leaves between 1910 and
1950 does in fact reflect formal state and psychiatric discourse.
The historiography of mental health deinstitutionalization in 20thcentury Quebec, i.e., the reinsertion of institutionalized people into society, has been particularly one-dimensional.5 The main pioneers of this
field of study in Quebec were Françoise Boudreau, Henri Dorvil, and
Hubert Wallot.6 Their works have inspired many graduate and postgraduate studies over the last 15 years.7 However, the angle from which
deinstitutionalization has been studied to date has been mainly sociological.8 Aligned with anti-institutional analyses, these studies were primarily interested in debunking the myth of the asylum as a place where
patients were actually being healed, exposing, for example, the tendencies of these institutions to use the asylum as a place to exert social control and where patients were commonly abandoned and dehumanized.
The seminal works of Dorvil, a specialist in the “transinstitutional” phase
in Quebec, focus more on the precarious situation of the mentally ill in
the community since the social reforms of the Quiet Revolution. These
studies are supported by powerful testimonials from survivors of the
so-called asylum era.9
The question of the links between the psychiatric institution, Catholicism, and the Quiet Revolution has been examined by Boudreau, who
affirmed that until 1960, francophones perceived madness as an incurable evil inflicted by God to punish or test an individual.10 Boudreau
also claimed that “[t]he mentally ill person was thus “placed” in the asylum, and the Sisters, due to their spirit of self-sacrifice and commitment
to lead a life of chastity, poverty, and obedience, were considered best
qualified to take care of the afflicted and to save their souls.”11 Her
analysis, in addition to being anti-institutional, is strongly marked by
128
anti-Catholicism. Nérée St-Amand, for his part, offered an original contribution by focusing on alternative practices and spirituality in mental
health in Ontario and New Brunswick.12 More recent works by Wallot
focus on the drama of the forced confinement in psychiatric institutions of the so-called Duplessis Orphans, examining in particular the
institutional transfers that marked the lives of an entire generation of
children that was afflicted or presumed to be afflicted with an intellectual deficiency.13
Among historians and sociologists, a reframing of Catholicism in Quebec has been taking place for the past 10 years, in particular by Michael
Gauvreau, Jean-Philippe Warren, Éric Bédard, Lucie Ferretti, and E. Martin Meunier.14 The notion of the backwardness of a traditionalist and
reactionary Quebec ruled by the clergy is challenged on the basis of
analyses of Catholic social movements rooted in a type of personalism
advocated by Emmanuel Mounier throughout the 1930s and 1940s.
According to Gauvreau, the Quiet Revolution originated in the crisis of
the 1930s and the Catholic Action movement. His study, based on Quebec culture and society at the time, shows that the first phase of the
Quiet Revolution was driven by a desire for a new Catholicism in which
institutions were directed by laymen.15 The second phase of the secularization of Quebec society, which began in the mid-1960s, rejected
Catholicism as a force of social change. This second stage, realized by an
elite group of middle-class intellectuals in the 1950s and 1960s, overshadowed the actions already undertaken in this regard by social and
popular movements (workers, youth, and women) of the lower classes.16
The authors of the Bédard Report belonged to this elite.
Our study is part of this recent historiographical current, which advocates a re-evaluation of the pre-Quiet Revolution period in Quebec that
considers a social Catholicism to be one of the main drivers of the changes
in Quebec society. Our aim is to contribute to this research by showing
that—through their policies, strategies, and practices—the Sisters of Providence and the psychiatrists of Saint-Jean-de-Dieu Hospital implemented
a system for the reintegration of patients into their families starting in the
1910s. A study of the archives allows us to dispel the commonly held
view that credits the “modernist” psychiatrists, trained in the 1950s, with
having created a new way of helping the mentally ill through the psychiatric reforms they implemented in the 1960s.17 Instead, our findings
show that this generation of psychiatrists, the authors of the Bédard
Report, was only continuing a system that had already been in place for
half a century. In fact, the massive wave of deinstitutionalization that
took place in the 1960s and 1970s was due less to “modernist” psychiatric
practices than to the arrival of psychopharmacology in 1954.
This first part of this article deals with the asylum context from 1910 to
1950. The official discourse of the decision-making bodies that dealt with
129
the status of the mentally ill was instrumental in shaping the policies and
laws to which the psychiatrists succeeding the superintendence of SaintJean-de-Dieu were subject during the first half of the 20th century. These
policies, though primarily aiming to relieve overpopulation in asylums,
also reflected changes in the perception of the causes of mental illnesses,
the desire of psychiatrists for psychiatry to be considered a legitimate
medical specialty, and the arrival of new treatment methods. The second
part of this paper, based on meticulous studies of medical files, reflects an
overall alignment with the official discourse concerning efforts to reduce
overcrowding in asylums. Some of these findings point to a part of asylum history that has remained largely unknown to date, namely, the
existence of a “pre-deinstitutionalization” phase during which psychiatric patients were already being “dehospitalized.”18
THE ASYLUM CONTEXT: POLICIES, DISCOURSE, AND INSTITUTIONAL
PRACTICES, 1910–50 19
At the end of the 19th century, the Quebec asylum system was criticized
because its patient population consisted of a mix of incurable patients,
the criminally insane, and patients who did not qualify as insane. In
1885, a government law placed the control of asylums into the hands of
medical superintendents, doctors paid by the state. However, at SaintJean-de-Dieu, the administration remained in the hands of the Sisters of
Providence.20 During the same time, the then medical superintendent,
Dr. Bourque, adopted Magnan’s theory of degeneration, according to
which illnesses were classified into two main groups: those with organic
causes, such as madness resulting from degeneration, and those with
functional causes, such as chronic delirium. On the basis of that theory,
so-called mad people were perceived as being ill and their madness was
associated with an injury, an arrested development of the brain, or
heredity.
In 1900, the medical superintendence of Saint-Jean-de-Dieu Hospital
was passed to Dr. Villeneuve, who held the position until his death in
1918. At the medical level, the hospital aligned its classification system
with those of similar institutions in Quebec, and also introduced work
therapy, temporary leaves, and discontinued mechanical restraint measures.21 On the whole, the discipline of psychiatry was increasingly identifying itself as a medical specialty that prevented and treated mental illnesses. This led to committing people who presented with even minor
symptoms, which increased the asylum population and also expanded
the set of behaviours associated with mental illness.22 Thus, the psychiatrists were readily accepting large numbers of patients, seeing the
hospital as a place that treated and prevented illnesses rather than a
means of ridding society of its “mad.” The increasing asylum population,
130
in turn, then led to problems with financing and funding.23 It was not
until several years later, in the 1920s, that the mental hygiene movement in Quebec began to advocate the prevention of mental illness outside of the walls of the asylum.24
LOI SUR LES ASILES D’ALIÉNÉS OF 1909: PREMISES FOR A NEW TYPE OF
ASYLUM MANAGEMENT
The Loi sur les Asiles d’aliénés of 1909, a consolidation of the law of 1880,
governed the commitment process until 1950. Sections 4105 and 4115 of
the Act legislated the grounds for granting “voluntary” commitment.
This Act stipulated that,
(4105) Peuvent être admis dans les asiles d’aliénés, aux frais du gouvernement
[…]
1.- Les aliénés qui n’ont pas par eux-mêmes, […] les moyens de payer […].
2.- Les idiots ou imbéciles, lorsqu’ils sont dangereux, une cause de scandale,
sujets à des attaques d’épilepsie, ou d’une difformité monstrueuse et sont incapables de payer leur entretien, leur séjour et leur traitement en tout ou en
partie; […]
(4115) […]Étant donné qu’un individu est aliéné, son internement peut se justifier, soit comme mesure de thérapeutique, d’assistance ou de sécurité publique et
privée et d’ordre public. À part la certitude que l’individu est aliéné, le surintendant médical devra trouver dans le certificat médical, une raison suffisante
pour l’interner, à l’un de ces trois points de vue. Ce ne sont pas de vagues présomptions, ce sont des faits que le médecin devra apporter à l’appui de son
opinion, lorsque les indications de l’internement ne se déduisent pas exclusivement de la forme particulière d’aliénation mentale dont souffre l’individu.25
Certain behaviours demonstrated the need to isolate individuals from
the rest of society and to initiate the admissions process. Within the meaning of the Act, who could be committed? The law was precise. The insane
could be committed for three reasons: (1) to care for them, (2) to help
them, or (3) as a security measure and to maintain social order in public
life as well as at home. In the case of so-called idiots and imbeciles, they
could only be committed if they were dangerous or scandalous, epileptic,
or “monstrous.” However, the definition of what qualified as scandalous
or dangerous was not provided by the Act and behaviour deemed as
such responded in fact to a criterion of tolerance based on the mores and
values of that era. The decision rested with the individual psychiatrists,
i.e., men who saw and thought in a particular context. The first two justifications for having someone committed, namely, for therapeutic and
assistance factors, were rarely invoked during admissions.
What criteria then could be used to diagnose an insane individual?
Dr. Tétreault, a psychiatrist at Saint-Jean-de-Dieu in the 1910s and 1920s,
had a precise response: although he admitted that it was difficult to
131
establish categories for the dangerously insane, he contended that any
insane person could be dangerous at any given moment.
1) Pour lui-même, lorsqu’il est sérieusement exposé à attenter à ses jours ou à
compromettre sa fortune, soit en se laissant exploiter par son entourage, soit en
s’abandonnant lui-même à des projets extravagants.
2) Pour autrui, lorsqu’il y a lieu de craindre qu’il n’attente à la pudeur ou à la vie
des personnes, qu’il n’incendie ou ne détruise les propriétés.
3) Pour la société, quand, par ses écrits, ses paroles ou par ses actes, il compromet
l’ordre public ou augmente indûment les charges sociales dans les cas, par exemple, d’enfants procréés par des idiotes laissées en liberté.26
With the onset of the medicalization of social deviance, psychiatrists
implemented a commitment practice that was to be strongly criticized
half a century later. Although temporary leaves had been in effect since
1909, social pressures and stigmas related to immoral and scandalous
behaviour created tension between those who tended to advocate the
isolation of patients and those more disposed to releasing patients from
the institution.
After the death of Dr. Villeneuve in 1918, the assistant medical superintendent, Dr. Francis Eugène Devlin, held the interim position until
1931. When the Sisters of Providence’s contract with the government
expired, the Sisters recognized the need to concern themselves with the
state of the infrastructure and to be up-to-date with the latest medical
techniques. Hydrotherapy was implemented in 1921, followed one year
later by occupational therapy with specialized staff.27 At the same time,
the first social worker, Marie Migneault, was hired as an enquiry officer.
In a letter to Dr. Desloges in February 1921, Dr. Devlin stressed that all
large hospitals in North American had enquiry officers with jurisdiction over both the medical and economic aspects of patient care. The
documents produced by these officers provided insight into the patients’
history before their commitment; assisted in decision-making concerning
temporary leaves, readmissions, and definitive releases; and allowed
the evaluation of the financial situation of the patients’ families in order
to determine their level of participation in the cost of treatment.28
In 1923, for 3,019 patients, there were 280 nuns (72 of whom were
registered nurses), 58 secular nurses, 4 psychiatrists, nearly 10 consulting
doctors, 1 surgeon, 1 dentist, and 1 ear-nose-and-throat specialist.29
Seven years later, Saint-Jean-de-Dieu Hospital had 4,165 patients, 23
professionals, a dozen doctors (including internal psychiatrists and consultants), and 6 specialists.30 With an increase of more than 1,000 patients
in less than 10 years, the attempts of Dr. Villeneuve between 1900 and
1910 to restrict the asylum population, as stipulated by the Act of 1909,
had not borne fruit. In 1932, Drs. Noël and de Bellefeuille reiterated that
Saint-Jean-de-Dieu was not supposed to receive certain types of sick
132
people, such as non-delirious epileptics and “minor mental cases” such
as “pithiatistic, psychasthenic, neurasthenic, and mentally retarded
patients.”31
The increase in the asylum population went hand in hand with the
increase in the Quebec population, which more than doubled between
1881 and 1931, rising from 1,359,027 to 2,874,662. The province also underwent rampant urbanization during the same period, with the urban population increasing from 36% in 1901 to 60% in 1931.32 Although the great
exodus to the United States alleviated this demographic pressure somewhat, the rural exodus within Canada nevertheless contributed to urbanization and overpopulation in working-class neighbourhoods. Some
90,000 people are estimated to have emigrated from the country to the
city within one decade alone, between 1921 and 1931.33
Table 1
Populations of the Province of Quebec and the Greater
Montreal Region, and the Proportion of the Overall
Urban Population in Quebec34
Province of Quebec
City of Montreal
Island of Montreal
Census Metropolitan
Area
Urban population
1911
1921
2,005,776 2,360,510
467,986
618,506a
543,449
724,305
–
–
1931
2,874,662
818,577
1,003,868
1,023,158
1941
3,331,882
903,007a
1,116,800
1,139,921a
1951
4,055,681
1,021,520a
1,320,232
1,395,400a
44.5%
59.5%
61.2%
66.8%
51.8%
a Indicates that the territory has changed since the preceding census.
As of 1931, the population growth rate of the asylum by far exceeded that
of the province.
Table 2
Total Population of Patients at Saint-Jean-de-Dieu, 1911–51
Year
Total Population
1911
1916
1921
1926
193135
1936
1941
1946
1951
2,000
2,443
2,962
3,653
4,179
5,706
6,814
7,054
6,010
Sources: Annuaire statistique du Québec, 1911 to 1951.
133
Psychiatrists and other healthcare professionals of the era took social
factors into account when diagnosing mental illness. The First World
War and the economic crisis from the early 1920s to the 1930s necessitated state intervention in the social sphere.36 In the context of those
economic and social difficulties, the number of people in need increased.
Between 1930 and 1939, the asylum population rose from 4,165 to 6,548
patients. This significant increase then led to another problem: a lack of
resources and infrastructure to accommodate it.
The reforms of 1926 and 1928 reflected a strong willingness to view
the asylum not as a place of confinement but as a hospital that treated
and healed. The reforms can also be seen as a continuation of actions
already begun with the creation of the nursing school at Saint-Jean-deDieu in 1912.37 The most important impetus for change was the high
proportion of patients deemed incurable, which had reached 50% by
1931.38 Pharmaceutical services using herbs, teas, barbiturates, and bromides officially began in 1928. From 1929 until 1951, shock treatments
were also administered to treat syphilitics, namely the malaria therapy of
Von Jauregg.39 Sakel’s insulin coma therapy and convulsive therapy, also
called Metrazol shock therapy, developed by Von Meduna, were put
into practice soon after. The arrival of penicillin in 1938 allowed the
treatment of degenerative neurological infections such as syphilis.
After 43 years of service, Dr. Devlin retired in 1931. Dr. Omer Noël, the
medical assistant at Saint-Jean-de-Dieu since 1908, then became the medical superintendent and held the position until 1952. The increased number of people committed, despite temporary leaves and the Act of 1909
that prohibited the admission of idiots and imbeciles who were not dangerous, necessitated the construction of new pavilions. Although
Dr. Noël complained of the high rate of incurability of the “senile
demented patients, idiots, or imbeciles, for whom a recovery is impossible but who inevitably decrease the overall recovery rate of the treated
population,” Saint-Jean-de-Dieu continued to accommodate both
chronic and “curable” cases.40 In 1933, Dr. Noël stated that the role of the
hospital should not be simply to keep people who are more or less dangerous, but to ensure the treatment and recovery of the sick. He also
pointed to the many prejudices that stigmatized the hospital and the
insane. Faced with the growing asylum population, he advocated to the
minister of health the creation of special hospitals for alcoholics and
drug addicts, who were considered very different from other patients, as
they required constant surveillance.41
In his annual report of 1935, Dr. Noël extolled the fact that advances in
medicine had increased the life span of the insane, commenting as well
on the challenging consequences thereof on the financing of insane asylums. He also emphasized the increased rate of recovery among the
mentally ill, estimating a recovery rate of 25% or higher. However,
134
according to our data and calculations, the rate was in fact only a meagre
2%.42 At the request of the superintendent, a new doctor, Dr. Jean PanetRaymond, was then appointed to tackle the increase in the asylum population. In 1937, Saint-Jean-de-Dieu Hospital had 22 doctors, 392 nuns, 41
nurses, 188 guardians, 149 secular nurses, and 246 employees for 6,064
patients, 1,189 of whom were on temporary leave.43 The number of
patients represented 47% of the total population of the mentally ill confined in the seven psychiatric hospitals in the province of Quebec, which
was estimated to be 12,786 in 1937.44
To improve follow-up of patients on temporary leave and verification of the financial situations of their families, a second social worker,
Annette Labonté, was hired in the 1930s to assist Marie Migneault, who
had been in the position since 1921. But it was not until 1936 that a
Department of Social Services was set up, with the mandate to coordinate the work of social workers.45 The department kept records of the
financial, social, and family situations of the patients, including their
relationships with their families.46 By the early 1940s, the service, still
staffed by no more than these two social workers, was no longer able to
adequately respond to the needs of the increasing number of mentally
ill. Reforms were thus needed.
In 1941, a public health official, Mr. Gauthier, proposed a solution to
the problem of overpopulation, one which he had previously proposed
in the early 1930s, namely, the establishment of external clinics within
Quebec’s public healthcare system for patients who could be treated
outside the hospital.47
L’hôpital pour aliénés formera ce qu’il est convenu d’appeler un service
extérieur; un médecin neuro-psychiatre possédant une certaine expérience est
choisi et ses fonctions consisteront d’abord à connaître les malades qui sont
encore dans les services, mais dont l’amélioration ou la guérison laisse prévoir
une sortie prochaine de l’hôpital. […] [À la sortie du patient, le médecin se
rendra régulièrement aux dispensaires proches de son lieu de vie, selon des
rendez-vous donnés d’avance.] Le médecin se rendra compte de l’état du
patient, de l’évolution de sa maladie, de sa réadaptation sociale, en somme de
son utilité ou de sa nuisance à la société en général.48
He called for a “real” hospital for mental diseases rather than a “kindergarten” mandated only with the safeguarding of people who were
harmful or dangerous to themselves or society.49 In that sense, he criticized the Act of 1909 on the grounds of its admission policies, which
focused mainly on social deviance (i.e., dangerousness, asociality, and
scandalousness), and advocated that psychiatric institutions justify commitment and treatments on “pathological” bases rather than focusing on
the social management of deviance. Although Gauthier and later Sister
Louise of the Assumption (a social worker at Saint-Jean-de-Dieu) used
135
the term “kindergarten,” the historiography shows that “dumping
ground,” in reference to the term “social waste” employed by Dr.
Desloges, would in fact have been a more apt expression.
THE ACT OF 1941: AN ATTEMPT TO REFUSE CHRONIC CASES
Amidst critiques concerning the steep increase in the asylum population,
the Loi sur les aliénés (Insane Persons Act) of 1941 was intended to dissuade people from getting an insane person admitted to an insane asylum without abiding by the official procedure. This Act stipulated that
quiconque, dans le but, ou de s’en débarrasser lui-même, ou d’en débarrasser
un autre, ou de le faire interner dans un asile pour les aliénés ou les idiots, ou
dans toute autre institution de bienfaisance subventionnée par la province,
laisse ou dépose dans un endroit quelconque un aliéné, un idiot, un dément, un
épileptique, un sourd-muet, un malade ou un infirme quelconque […] est passible d’une amende, d’un emprisonnement de six mois dans la prison commune du district où l’infraction a été commise.50
On the basis of the Act of 1941, many cases of senile dementia, mental retardation, simple epilepsy, and alcoholism were refused at SaintJean-de-Dieu, unless, as stipulated by the Act, the persons were dangerous or scandalous and harmful to the public peace. The work of the
social workers seeking to reinsert the chronically sick into their families, together with the laws prohibiting the insane from being “dumped”
in an asylum without permission, were strategies aimed at decreasing
the asylum population.
Regarding this situation, Sister Louise of the Assumption reiterated
that the goal of insane hospitals was to offer treatment for those with
mental illness rather than to function simply as a holding place for the
mentally unstable.
L’importance capitale d’institutions dans le genre de l’hôpital Saint-Jean-deDieu, au point de vue social, et en second lieu, en vue de bien convaincre par
des faits et des chiffres qu’un hôpital spécialisé pour le traitement des maladies mentales n’est pas une simple garderie de débiles mentaux, encore moins
un asile où sont détenus de pauvres êtres dangereux pour la société, mais un
hôpital, un hôpital bien spécialisé où l’on traite, où l’on guérit les maladies
mentales. [sic] […] Avec les besoins toujours grandissants, le contrôle social
est devenu beaucoup plus difficile à maintenir du fait des agglomérations dans
les villes. Dans ces temps d’inquiétude et de malaise, les troubles mentaux sont
de plus en plus fréquents et nos hôpitaux spécialisés en maladies mentales ne
peuvent suffire à recevoir ceux qui cherchent une cure.51
Although 1947 statistics show that 54% of the patients admitted that
year were deemed incurable, there was already a strong willingness to
return them to their family homes or transfer them to another type of
136
institution for the chronically ill and inoffensive.52 It is worth noting
that since the 1920s, the government of Quebec had been creating new
types of institutions that were more specialized, such as the Bordeaux
Hospital for Insane Prisoners founded in 1926, followed by, in the 1930s
and 1940s, the reform school Saint-Jean-de-Bosco for delinquents, the
École Emmélie-Tavernier for intellectually disabled youth, and the asylum Sainte-Anne à Baie Saint-Paul for chronically ill patients. Saint-Jeande-Dieu Hospital, for its part, wanted to continue treating mentally ill
adults suffering from organic or psychological problems. Advances in
medicine with the discovery of antibiotics, and the improvement of living conditions after the Second World War, helped to alleviate the challenges facing psychiatry. However, although research into the psychological causes of mental illness did begin as of 1940, the majority of
psychiatrists working inside the asylum concentrated on the physical
causes of mental diseases. Thus, the psychogenic causes of these diseases remained poorly understood and adopted, in particular, due to
the fact that most patients were long-term patients with chronic illnesses. The organogenic causes of mental illness had in fact been the
main object of study since the end of the First World War, with the onset
of the development of neurology. These studies soon led to the discovery of chlorpromazine, a neuroleptic distributed under the name
Largactil.
The “asylum” officially became a “hospital,” the “insane” became the
“mentally ill,” and “commitment” became “hospitalization,” pursuant
to the new Loi des institutions pour malades mentaux of 1950. The hospital
became a place where ill people were treated rather than an asylum
where they were simply kept. This Act provided that:
peut être admis dans un hôpital tout malade chez qui le désordre mental constitue l’élément prépondérant de son état pathologique.[…] Lorsqu’un médecin
est d’avis qu’il est nécessaire, pour la protection de la vie d’un malade mental
ou pour la sécurité, la décence ou la tranquillité publique, de le faire admettre
dans un hôpital il peut obtenir de tout juge des sessions, magistrat de district,
recorder ou juge de paix de la localité où se trouve le malade, une ordonnance
de transport de ce dernier dans un hôpital.53
When the Bédard Report of 1962 was putting an end to the outdated concept of the asylum, Saint-Jean-de-Dieu Hospital had already
become a medically modern institution, according to the criteria of the
era. The period of massive deinstitutionalization thus began. In that
regard, Dr. Bordeleau, a psychiatrist at Saint-Jean-de-Dieu in the 1960s,
stated that it was necessary for society to change its ideas about psychiatric institutions along with the transformation in care of the mentally ill:
137
la société qui demande qu’on enferme le malade mental sans se préoccuper
continuellement de l’évolution de l’institution qu’elle a réclamée à cette fin. […]
Quoique l’hôpital psychiatrique représente pour la société une sorte de honteuse néo-formation et lui cause ainsi une profonde blessure narcissique, il est
évident que nous sommes incapables de nous en passer et que nous devons
l’utiliser dans les meilleures conditions possibles.54
During the sixties, a new generation of psychiatrists was ready to take
charge of the institution, which at the time still belonged to the Sisters of
Providence. This chapter of its history came to a close in 1974, when
Dr. Lazure became the director of Saint-Jean-de-Dieu Hospital, at which
point the hospital was renamed the Louis-H.-Lafontaine Hospital.
THE “DEHOSPITALIZATION” OF THE MENTALLY ILL OF
SAINT-JEAN-DE-DIEU
Thanks to the access to the medical archives of Saint-Jean-de-Dieu Hospital granted us within the framework of different research projects, we
had first-hand insight into highly valuable primary source documents.
Of particular value were Form J (request to temporarily keep an insane
person on temporary leave)55 and letters regarding the state of health of
the insane during their temporary leaves within the family setting. These
sources provided us with an overview of the comings and goings of
patients between the hospital and their family settings and the various
attempts at social reinsertion. The practice of granting temporary leaves,
still uncustomary at the turn of the century, started to become more
common at the end of the first decade of the 20th century. They served
as a measure to relieve an evergrowing population in psychiatric hospitals in the years before the prosperous post-World War II decades—the
so-called Glorious Thirty—that were characterized by significant injections of government funding into healthcare.56
TEMPORARY LEAVES
During a temporary leave, the mentally ill were allowed to leave the
asylum for a period of three months, even if their state had improved
only a little, or even not at all, since their initial commitment. Provided
the patients did not represent a danger to themselves or their families
and communities, they were allowed to return home for a vacation or a
trial period before a definitive discharge from the asylum was requested.
If all went well, a three-month extension of the temporary leave could be
requested. However, if the family found that it was impossible to keep
the mentally ill patient with them, they had the option to readmit the
patient to the asylum without having to go through the admission
formalities again.57 The possibility of returning the mentally ill to the
138
asylum remained an option at all times and served as a safety net for
families who had decided to take care of their mentally ill family members outside of the asylum walls.
The people who applied for a temporary leave and who were authorized to pick up the patients from the asylum agreed to communicate,
every thirty days, with the medical superintendent about the evolution
of the physical and mental state of the patient on temporary leave. If the
doctor was not contacted and updated regularly, he would contact the
family to remind them of their obligation. Based on the correspondence
regarding this procedure, it was possible for us to obtain more detailed
information about the patients’ stays outside of the asylum walls. News
of the patients—generally fairly positive—was communicated to the
superintendent by the village doctors, the responsible family members,
or sometimes the patients themselves. It appeared that the state of mental health of one out of every two patients improved during a temporary
leave.58 Of the temporary leaves that were documented with correspondence, the patients’ states improved in 49% of cases, and remained
stable for the majority.59 An improved state, reported by the family,
meant that the patient exhibited manageable behaviour without causing
too many problems and that the family therefore wished to extend the
trial period for another three months. Letters requesting an extension of
the temporary leave would usually sound similar to this one: “« Jusqu’ici
nous n’avons encore eu aucun trouble avec Irène, cependant si vous
voulez être assez bons de lui accordé encore une petite vacance, je vous
en serai très reconnaissant ».60
Unquestionably, family assistance, support, and involvement during
patients’ detentions for mental disorders directly influenced their
chances of leaving the asylum one day, independent of their mental
state. Historian Ellen Dwyer also remarked on this aspect with regard to
the patients at Utica Asylum in New York: “Utica’s patient casebook
records suggest that most patients were released only if and when their
families promised to take subsequent care of them.”61 During a temporary leave, many patients experienced improvement during the three,
six, and even nine months before having to be readmitted to the asylum
because they had become uncontrollable. The people in charge of an
insane person cautiously favoured an extension of a temporary leave
over a request for a definitive discharge of the patient, as indicated in the
following excerpts from two letters:
Comme le congé que vous avez accordé à ma petite fille idiote Aurore […] est
presque écoulé j’ose vous écrire ces mots pour vous demander le prolongement de son congé son père et moi nous aimerions bien à la garder encore
quelques temps d’ailleurs elle est assez tranquille il est vrai qu’elle a encore de
temps à autre quelques petites crises mais modérées. Nous lui donnons du
brandy et du lait tous les soirs nous lui donnons jamais de viande elle a assez
139
d’appétit mais nous la privons de trop manger. Mais ce qui m’inquiète le plus
Docteur s’il fallait par malheur qu’elle aurait encore des grandes crises comme
auparavant est-ce que nous pourions la ramener à l’asile sans trop de difficultées.62
Depuis que la patiente est revenue au milieu de nous elle semble se porter
assez bien au physique, elle a bon appétit, son sommeil est calme et ne se croit
plus persécutée comme avant son séjour à l’hôpital. Cependant, ce qui nous
cause un peu d’inquiétude, c’est qu’elle paraît un peu taciturne. Nous ne pouvons pas dire maintenant qu’il y a guérison complète voyant que sa maladie a
présenté par le passé des alternatives de dépressions et de surexcitations
nerveuses. Nous croyons donc pour le moment qu’il est plus prudent de
demander une extension de congé.63
These health reports submitted to the medical superintendent clearly
manifest the anxiety, insecurity, and apprehension experienced by the
families who decided to keep their ill family members among them. The
fear of a new crisis, a relapse, or the degeneration of the mental health of
the presently manageable insane person was a consistent concern of
the family, whether parents, spouses, siblings, or extended family members, who assumed responsibility for the sick outside of the asylum
walls. The opportunity to extend the temporary leave and the guarantee
of being able to return the patient to the asylum if their mental state
worsened gave families the incentive to continue prolonging the trial
periods of reinserting their insane relatives into the family setting:
« Notre cher Henri […] est assez bien dans le moment, mais nous ne
pouvons pas encore croire à une parfaite guérison. Veuillez donc nous
accorder encore une extension du congé, en faveur de notre malade,
pour trois mois ».64 Since such messages were common, the medical
superintendent in some cases felt obliged to inform families that the
time had come for them to definitively take charge of the patient now
considered recovered: « Madame, comme d’après votre lettre, votre mari
semble guéri et qu’il est déjà absent depuis 6 mois, j’ai l’honneur de
vous informer qu’il n’est pas opportun de prolonger davantage son
congé et qu’il a été mis en sortie définitive aujourd’hui ».65
Temporary leaves were a positive experience for many families and
offered patients the opportunity to leave the institution, thereby increasing their chances of ultimately obtaining a definitive discharge. Evidently, the asylum performed very well in taking charge of patients
considered to be in crisis, dangerous, or “disorganized.” However, once
the insane manifestations were under control, the institution did not
appear to be able to offer any more than what could be provided by families who generally made efforts to provide care for their ill family member.66 According to historian Nancy Tomes, “One might argue that those
patients who improved would have improved anyway regardless of the
140
treatment they received at the Pennsylvania Hospital for the Insane.”67
Moreover, temporary leaves proved favourable for the social integration of the mentally ill and were excellent ways for them to maintain
contact with their families. The leaves also allowed families to closely follow the evolution of the mental state of their sick relative and to participate in their rehabilitation. The success of temporary leaves was demonstrated in 1912 by the definitive discharge of 68% of the patients who
had been granted a stay with their families. In 1960, 44% of patients
were discharged after obtaining a temporary leave.68
ATTEMPTS TO REDUCE OVERPOPULATION IN THE ASYLUM
Temporary leaves also quickly become a strategy implemented by the
medical superintendents to reduce overpopulation in the asylum. The
superintendents recommended temporary leaves by sending letters to
the families asking them to come pick up their sick relatives, now deemed
to be in a satisfactory state. This is demonstrated in the following letter,
written by Dr. Villeneuve: « J’ai le plaisir de vous informer que Gérald est
susceptible de sortir en congé d’essai. Je vous prie, en conséquence, de
venir le chercher au plus tôt […] ».69 A dozen years later, the tone of such
correspondence had become more insistent, as demonstrated by the following letter from Dr. Devlin, with families being reminded of the law
prohibiting the confinement of those not considered dangerous and
threatened with having the patient returned at their own cost:
Monsieur,
J’ai l’honneur de porter à votre connaissance que Catherine [nom de la
patiente], admise à cet hôpital le 30/6/93 à votre demande, est une aliénée incurable chez qui nous n’observons pas actuellement de réactions dangereuses ou
scandaleuses. Cette patiente tombe donc sous le coup de l’article 4152 S.R.Q.
1909 qui se lit comme suit :
« Le secrétaire de la province ou le surintendant médical sur l’autorisation
écrite du secrétaire de la province peuvent ordonner que les idiots, les aliénés
incurables ou les déments séniles sortent de l’asile où ils se trouvent, pour être
envoyés dans leurs familles, ou chez les personnes tenues en loi à leur entretien,
ou dans les hôpitaux dans lesquels on reçoit les vieillards et les malades; pourvu
toujours que ces malades ainsi libérés ne soient pas une cause de scandale ou de
danger .»
Pour me conformer aux instructions reçues de l’honorable Secrétaire de la
Province, et transmises par le Directeur Médical Général des Hôpitaux d’aliénés,
et me prévalant des dispositions de l’article cité plus haut, je vous enjoins de
venir la chercher immédiatement. Sinon, elle vous sera retourné à vos propres
frais. Je dois vous dire qu’elle sera mise en congé d’essai.70
Letters of this kind were often received without enthusiasm. Memories of the troubles caused by the insane behaviour of the patients dis-
141
couraged many families from coming to seek their relatives, as revealed
by this excerpt: « Le pauvre vieux leur a fait tant d’ennuis dans le passé,
qu’il leur répugnerait énormément de le voir revenir, de crainte que ces
mêmes ennuis ne se renouvelassent ».71 Sometimes, however, the family
situation simply did not allow them to care for an insane person, at least
over the long term: « Mme [cousine] aimerait la garder, mais elle a déjà
quatre enfants et son mari [s’oppose?] à ce qu’elle reçoive Mlle [patiente]
pour des congés trop longs. Elle la reprendra aussi souvent que cela lui
sera possible.»72 Between 1934 and 1949, this patient, suffering from
mental debility and epilepsy, and taken in alternatively by her cousin
and brother, was released a dozen or so times on six-month temporary
leaves. During each of the temporary leaves, the patient was readmitted
on average eight days after discharge.73
Another means implemented to relieve psychiatric institutions, which
were admitting more and more patients every year without showing
large numbers of definitive discharges, were notifications of transfer.
The medical superintendent would send a notice to the family indicating
that the patient had been (or would be) transferred to an institution
specialized in the treatment of incurable patients, as illustrated by the following excerpt: « J’ai l’honneur de vous informer qu’à cause de l’encombrement qui existe présentement à l’hôpital Saint-Jean de Dieu, il
nous est impossible de garder plus longtemps votre malade ».74 In this
way, patients who had no chance of recovery were discharged from the
asylum . Some were sent to smaller psychiatric hospitals such as Hospice
de Mastaï, close to Quebec City, or to Saint-Charles de Joliette Hospital.
Others were transferred to Baie St-Paul Hospital, which was newly built
and designed to accommodate incurable patients requiring special care.75
However, as these transfers generally involved moving patients far away,
many families objected. In the following excerpt, a mother explains to
Dr. Devlin that she would no longer be able to visit her daughter were
she to be transferred:
Dernièrement, il était question d’envoyer ma fille à Baie St-Paul, Mon enfant est
a votre hopital depuis vint ans et ce que je veux vous demander, c’est de la
garde chez vous. Vous comprenez très bien que c’est mon seul desennuie, aller
voir ma seule enfant souvent. Si donc vous l’envoyer plus loin encore, je ne
pourrai la voir si souvent et certainement, cela m’affecter beaucoup. Je suis
vieille, je sais que j’en ai pas pou longtemps a la voir, et je suis certain que vous
vous ferez un plaisir de m’accorder cette faveur.76
This case concerned the transfer of a patient who had been in contact
throughout her institutionalization with a relative, who had been incapable of taking custody of her. This procedure was also used to relieve
Saint-Jean-de-Dieu Hospital of patients considered to be “alone in the
world.” These examples are representative of this “de-hospitalization”
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phase, which was a main component of the organized deinstitutionalization process that was initiated “officially” by the Bédard Report in
1962, several decades later.77
Table 3
Population of Saint-Jean-de-Dieu on
temporary leave on December 31a
Year
Patients Present
Population on
Temporary Leave
% of Population on
Temporary Leave
1927
1932
1937
1943
1948
3,398
4,192
6,064
6,158
6,075
550
344
1,189
1,294
813
14%
8%
16%
17%
12%
aDocuments of the parliamentary session of the Province of Quebec.
Considering that in many cases it was difficult even for patients who
were in touch with their families to be discharged from the asylum, one
can only imagine how difficult it must have been for patients without a
family network.78 This was confirmed again by examining the discharge
of patients during the economic crisis of the 1930s, a time when many
families became too poor to take their sick relatives into their custody.
Moreover, due to the economic depression, many patients could not
take up the kind of work that they had done prior to their hospitalization
nor could they find another means of income to provide for their needs.
As a consequence, throughout that decade, the number of patients on
temporary leave dropped by half (Table 3). The popularity of temporary leaves then started to rise again in the year 1937, a trend which
lasted through 1943, at which time 17% of patients had left the asylum
temporarily to return to their family settings.79 However, by 1948, the
percentage of temporary leaves had again dropped, with only 12% of
patients granted a temporary leave. This percentage remained relatively
stable until 1960.80
OUTSIDE THE ASYLUM WALLS
Reintegrating into society patients who were not dangerous, yet for
whom psychiatric medicine had lost all hope of recovery, may have
been a favourable decision for the insane who benefited from family
support. The experience outside of the asylum walls often turned out to
be very positive and gave confidence to the family wishing to take under
its wing a family member afflicted with a chronic or periodic mental illness. In the following case, for example, a patient, who at age 60 had
143
been hospitalized for seven years for melancholy, was warmly taken in
by her family. The family received news that the patient was given a
definitive discharge, with mention of the word “recovered,” after it sent
the following letter to the medical superintendent:
Nous vous annoncons avec plaisir que Mde […] avec la grâce de Dieu est bien
mieux. Elle n’a jamais eu aucune idée délirante depuis qu’elle est arrivée au
milieu de nous son état physique et mental son bien bons exceptée qu’elle
enflée continuellement elle mange bien et rien la fatigue donc nous la
garderons avec bonheur tant que Dieu voudras nous là laisser.81
A temporary leave of three months had convinced her family that her
mental state was satisfactory. However, despite the good intentions of
patients’ families, some citizens of municipalities were strictly against
any return of “the undesirable,” as attested to by this petition, signed by
the plumber, grocer, notary, doctor, etc., and addressed to the authorities
of Saint-Jean-de-Dieu:
N’a jamais pu s’accorder avec ses parents, encore moins avec ses voisins. A
toujours été Kleptomane. A vécu « honteuse sordide » toute sa vie. Tous les
voisins et le quartier où elle demeurait ont subi ses atteintes judiciaires. (a toujours été en procès, même à l’heure actuelle). A subi deux condamnations en
cour de police pour avoir tenu une maison de débauches. Personnages à consulter [sept signataires].82
In another case, Saint-Jean-de-Dieu sought to orchestrate the discharge
of a patient admitted for psychoneurosis. The following request was
addressed to the patient’s lawyer from Dr. Noël:
Cher Monsieur,
J’accuse réception de votre lettre du 17 novembre courant, et je dois vous
dire que la malade ci-haut nommée [nom de la patiente] fait presque notre désespoir depuis qu’elle est à l’hôpital, en l’année 1933. Il me faut ajouter qu’elle a eu
des congés innombrables, et de même, elle en a pris sans permission 2 fois. Nous
l’avons placée peut-être 20 fois, et jamais elle n’a pu rester à ses places.
Je dois tout de même vous dire que nous n’avons pas perdu l’espoir, et nous
croyons qu’un de ces jours, il y aura un point pour elle quelque part. Si vous
voulez vous occuper d’elle, il me fera plaisir de la laisser sortir sous vos charges,
si vous m’en faites la demande [signature…]83
Evidently, the difficulty in getting this patient discharged was due less to
hospital authorities and more to the challenge of finding a responsible
person who would consent to being a warrant for her: « Mademoiselle,
Il sera difficile d’avoir votre libération […] il faudrait surtout avoir
quelqu’un qui se rendrait responsable de vous. En ma qualité d’avocat,
je ne puis le faire et il faudrait que vous trouviez quelqu’un de votre
famille si possible ».84
144
Despite families’ desire to have their sick relatives among them again,
the attempts to achieve this did not necessarily lead to the desired
results. After a temporary leave of two months accorded to her son, the
applicant, although initially believing that he « […] pourrait en venir à
bout », resigned herself to returning the patient to Saint-Jean-de-Dieu. As
indicated on Form J, the superintendent had no other choice but to
accept the return of the patient: « En réponse à votre lettre du 18 décembre, je dois vous dire que vous pourrez ramener votre malade quand
vous voudrez, vu qu’il n’est qu’en congé ».85 Nevertheless, thanks to
tenacity, perseverance, and courage of the families as well as the medical
superintendent, patients who had been on temporary leaves many times
throughout the 1930s, 1940s, and 1950s were among those definitively
discharged in the “first” wave of deinstitutionalization in Quebec.86
CONCLUSION
To the question À quoi sert l’histoire aujourd’hui? (Of what use is history to
us today?) historian Jacques LeGoff responded that it provided “a way of
interrogating the past, a kind of method of posing questions to the past
that allows us to be stronger and to redress what is presently not working in order to improve the future.”87 Subsequently, our survey on the
first half of the 20th century at St. Jean-de-Dieu hospital has tried to
respond to certain questions concerning the sombre past surrounding
the work of the Sisters of Providence since the 1960s. A study of primary sources and consultation of the asylum policies, psychiatric discourse, and the institutional practices led us, following the example of
the historian Guy Grenier, first to reject the thesis that the era was no
more than a dark age for the asylum, and then to contest the thesis of a
supposed backwardness of French-Canadian psychiatry.”88 Changing
political perspectives, in particular following the Act of 1909, and the
desire to relieve the overpopulation of the asylum, are clearly perceptible in the medical files, in which letters to families encourage them to
come pick up their sick relatives. Temporary leaves were therefore part
of a strategy to relieve asylum population during the first decades of
the 20th century, constituting one of the first initiatives to socially reintegrate the mentally ill prior to the Bédard Report of 1962.
The collective memory that holds that“[t]he priority of the deinstitutionalization movement in the 1960s was to release people from psychiatric hospitals,89 appears unaware that this “new” movement was in fact
harking back to already existing practices. The different strategies implemented by the medical superintendents throughout the first half of the
20th century to return the institutionalized mentally ill to their previous
milieu tempers, in our opinion, the importance generally accorded the
Bédard Report with regard to the implementation of deinstitutionaliza-
145
tion. The release of the Report in the 1960s is often seen as the pivotal
turning point that led to the exposure of the state of psychiatric institutions at that time.90 The alarmist discourse of its authors on asylum overcrowding, supported in the public arena through provocative articles in
newspapers such as Vrai, Le Devoir, and La Presse throughout the 1950s
and 1960s, denounced the disconcerting, if not frightening, state of the
Quebec psychiatric setting.91 Although historian Catherine Duprey
underlined that the Report had finally broken the silence, there had
been recurrent alarmist messages for many years from both the owners
and the psychiatrists of Saint-Jean-de-Dieu, as documented in their
annual reports since 1906.92 The state of overpopulation of the asylum
was described by Sister Sabithe in 1910 and again in 1913 by Dr. Villeneuve, who declared it was no longer acceptable to confine even the
incurably sick to “lock-up pens.”93
The strategies for returning institutionalized patients to their families
(or sending them to smaller hospitals) multiplied between 1910 and 1950.
Some patients benefited from repeated temporary leaves that often led to
permanent discharge from the asylum. Thus the the “first” wave of psychiatric deinstitutionalization following the Bédard Report may not have
been quite so novel. Decision-makers and modernist psychiatrists, perhaps
blinded by their new mission and desire to participate in the dismantling
of “the asylum” and the removal of religious staff, were only building on
a practice of social reinsertion that had long been in place.
ACKNOWLEDGEMENTS
The authors would like to thank Cathleen Poehler for her work in translating this article. They also thank the reviewers and the editors of the
BCHM for their commentary and helpful suggestions. An earlier version of this article was published in French in Social History/Histoire
Sociale.
NOTES
1 Archives of Louis-H. Lafontaine Hospital (AHL-HL). Medical file no. 9421.
2 This research project comes out of two other projects funded by the Canada Institutes of Health Research (CIHR): “Open Doors/Closed Ranks: Locating Mental
Health after the Asylum (2007–2012),” directed by Megan Davis and Erika Dyck;
and “Le champ francophone de la désinstitutionnalisation en santé mentale: enjeux
socio-historiques, normes et pratiques, 1920–1980 (2010–2013),” directed by MarieClaude Thifault. These two research projects on the history of mental health, more
precisely on the period of deinstitutionalization, offer a pan-Canadian reading of the
transition in the hospitalization of psychiatric patients in asylums to their reinsertion
into society.
3 Henri Dorvil, Herta Guttman, Nicole Ricard, and André Villeneuve, “Défis de la
reconfiguration des services de santé mentale,” Annexe 1., 35 ans de désinstitution-
146
4
5
6
7
8
9
nalisation au Québec 1961-1996 (Quebec: Report submitted to Quebec’s Ministre de la
Santé et des Services Sociaux, 1997), p. 109-121.
Marie-Claude Thifault, “L’enfermement asilaire des femmes au Québec: 1873-1921,”
PhD thesis, University of Ottawa, 2003, p. 245-46.
Our focus here is on the Quebec historiography, although we are aware that authors
outside Quebec have also dealt with issues and experiences in the transition in psychiatric care elsewhere. See, for examples, Peregrine Horden and Richard Smith,
eds., The Locus of Care: Families, Communities, Institutions, and the Provision of Welfare
since Antiquity (London: Routledge, 1998); Peter Bartlett and David Wright, eds., Outside the Walls of the Asylum: The History of Care in the Community, 1750-2000 (London
and New Brunswick, N.J.: Athlone Press, 1999); Gerald Grob, The Mad among Us: A
History of the Care of America’s Mentally Ill (New York: Free Press, 1994); Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton, N.J.: Princeton
University Press, 1991); Graham Mooney and Jonathan Reinharz, eds., Permeable
Walls: Historical Perspectives on Hospital and Asylum Visiting (Clio Medica Series, Wellcome Institute: Rodopi, London, 2009); and Catharine Coleborne, Madness in the Family: Insanity and Institutions in the Australasian Colonial World, 1860-1914 (Basingstoke:
Macmillan, 2010).
Françoise Boudreau, De l’asile à la santé mentale: les soins psychiatriques: histoire et institutions (Montreal: Éditions Saint-Martin, 1984); Henri Dorvil, “Nouveau plan d’action:
quelques aspects médiaux, juridiques, sociologiques de la désinstitutionnalisation,”
Cahiers de recherche sociologique, 41, 46 (2005): 209-35; Henri Dorvil, “La désinstitutionnalisation: du fou de village aux fous des villes,” Bulletin d’histoire politique, 10, 3
(2002): 88-104; Henri Dorvil, Histoire de la folie dans la communauté 1962-1987: de l’Annonciation à Montréal (Montreal: Éditions Émile-Nelligan, 1988); Henri Dorvil, “Les caractéristiques du syndrome de la porte tournante à l’Hôpital Louis-H. Lafontaine,”
Santé mentale au Québec, 12, 1 (1987): 79-89; Hubert Wallot, Peut-on guérir d’un passé asilaire? Survol de l’histoire socio-organisationnelle de l’hôpital Rivière-des-Prairies (Montreal:
Publication HMH, 2006) and Hubert Wallot, La danse autour du fou: entre la compassion
et l’oubli. Survol de l’histoire organisationnelle de la prise en charge de la folie au Québec
depuis les origines jusqu’à nos jours [preface by Camille Laurin] (Beauport: Publications
HMH, 1998).
Catherine Duprey, “La crise de l’enfermement asilaire au Québec à l’orée de la Révolution tranquille,” MA thesis, Université du Québec à Montréal, 2007; Brigitte Gagnon,
“Tout ce qu’on veut c’est vivre le plus normalement possible: Désinstitutionnalisation
psychiatrique et communautarisation des pratiques en milieu franco-ontarien,” MA
thesis, University of Ottawa, 1996; P. Morin, “Espace urbain montréalais et processus
de ghettoïsation de la population marginalisée,” PhD thesis, Université du Québec à
Montréal, 1994; Jacynthe Pitre, “APPLE : Un visage parmi tant d’autres. Un modèle de
pratique d’aide qui s’élaborent « hors les murs » de l’institution pour les psychiatrisées,” MA thesis, University of Ottawa, 1999; and M. Robert, “De la médicalisation à la pénalisation des justiciables souffrant de troubles mentaux,” PhD thesis,
Université du Québec à Montréal, 1997.
Louise Blais, Louise Mulligan-Roy, and Claude Camirand, “Un chien dans un jeu de
quilles: le mouvement des psychiatrisés et la politique de santé mentale communautaire en Ontario,” Canadien Review of Social Policy-RCPS, 42 (1998): 15-35; Marcelo
Otero, “Les fous n’existent qu’en société,” CREMIS, 3, 1 (Winter 2010): 16-20; and
Nérée St-Amand, “Dans l’ailleurs et l’autrement : pratiques alternatives et service
social,” Reflets, 7, 2 (Fall 2001): 30-74.
Jean-Claude Pagé, Les fous crient au secours (Montreal: Éditions du Jour, 1961); Bruno
Roy, Mémoire d’asile (Montreal: Boréal, 1994); Nérée St-Amand and Eugène Leblanc,
Osons imaginer. De la folie à la fierté (Moncton: Our Voice—Notre voix, 2008); and Luc
10
11
12
13
14
15
16
17
18
19
20
21
22
147
Vigneault and Marcel Blais, testimonial in the television series Les maudits fous! Vendome (2007).
This notion of madness is based on the ancient theory of humours, although emotional upheavals experienced during the first centuries of colonization were also
believed to play a role. In the 19th century, madness is increasingly explained as
being determined by heredity or as a pathological constitution. See Isabelle Perreault,
“Psychiatrie et ordre social: Analyse des causes d’internement et des diagnostics donnés à Saint-Jean-de-Dieu dans une perspective de genre, 1920-1950,” PhD thesis,
University of Ottawa, 2009. See also André Cellard, Histoire de la folie au Québec de 1600
à 1850 (Montreal: Boréal, 1991); Peter Keating, La science du mal (Montreal: Boreal,
1993); and Guy Grenier, Les monstres, les fous et les autres (Montreal: Trait d’Union,
1999).
Boudreau, De l’asile à la santé mentale, p. 54. The works of Boudreau were republished
in 2003 without modifications. Only annexe 4, which contains three recent articles by
the author, was added. See p. 273-335 of the 2nd edition (Montreal: Editions St-Martin, 2003).
Nérée St-Amand, “Le sacré : au cœur ou en marge du social,” Revue ontaroise d’intervention sociale et communautaire, 12, 1 (2006 ): 20-47.
Hubert Wallot, Peut-on guérir d’un passé asilaire? p. 160.
E. Martin Meunier, “Une nouvelle sensibilité pour les ‘Enfants du Concile?” in
Stéphane Kelly, ed., Les idées mènent le Québec (Québec: Les Presses de l’Université
Laval, 2003), 93-106; Michael Gauvreau, Les origines catholiques de la Révolution tranquille
(Montreal: Fides, 2008 [McGill-Queen’s, 2005 in English]; E. Martin Meunier and
Jean-Philippe Warren, Sortir de la Grande Noirceur. L’horizon personnaliste de la Révolution
tranquille (Sillery: Septentrion, 2002); Éric Bédard, Recours aux sources (Montréal:
Boréal, 2011); and Lucia Ferretti et Xavier Gélinas, ed., Duplessis: son milieu, son époque,
(Québec: Septention, 2010). Although focused on the social and cultural history of
Catholicism in Quebec, our research also examines the history of knowledge, institutions, the economy, and the actors. The first deinstitutionalization policies could not
have been implemented without a set of different variables.
Gauvreau, Les origines catholiques de la Révolution tranquille, p. 348-53.
For youth and women’s movements, see the studies by Lucie Piché, Femmes et changement social au Québec. L’apport de la Jeunesse ouvrière catholique féminine 1931–1966 (Quebec, Presses de l’Université Laval, 2003) and by Louise Bienvenue, Quand la jeunesse
entre en scène: L’Action catholique avant la Révolution tranquille (Montreal, Boréal, 2003).
Boudreau, De l’asile à la santé mentale, p. 140; Henri Dorvil, Herta Guttman, Nicole
Ricard, and André Villeneuve, Défis de la reconfiguration des services de santé mentale,
Rapport soumis au Ministre de la Santé et des Services Sociaux, Gouvernement du
Québec, 1997, p. 121-128.
[translation] “[D]ehospitalization releases diagnosed people from psychiatric hospitals.” Dorvil et al., Défis de la reconfiguration des services de santé mentale, p. 110.
For more details on the context of psychiatric knowledge, see Perreault, “Psychiatrie
et ordre social.”
Guy Grenier, “L’implantation et les applications de la doctrine de la dégénérescence
dans le champ de la médecine et de l’hygiène mentales au Québec entre 1885 et
1930,” MA thesis, University of Montreal, 1990, p. 50.
Bernard Courteau, De Saint-Jean-de-Dieu à Louis-H.-Lafontaine : Évolution historique de
l’hôpital psychiatrique à Montréal (Montreal, Méridien, 1989), p. 75.
Prevention took place inside the walls of the asylum, which had admissions policies
that favoured the commitment of large numbers of patients. This system led to considerable increases in the asylum population, and the underfinancing of institutions
of this kind in Quebec led to problems of financial management. See André M.
148
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
Paradis, “Le sous-financement gouvernemental et son impact sur le développement
des asiles francophones au Québec (1845-1918),” RHAF, 50, 4 (1997): 571-98. Starting
with the 1920s, the mental hygiene movement tried to prevent mental illnesses from
occurring outside of the walls of the asylum. See Guy Grenier, “Doctrine de la
dégénérescence et institution asilaire au Québec (1885-1930),” Cahiers du centre de
Recherches Historiques, 12, 1994, http://ccrh.revues.org/index2744.html. Accessed
15 April 2011.
Paradis, “Le sous-financement gouvernemental.”
In the United States in 1909, in English Canada in 1918, and in Quebec in 1928. For a
Canadian study, see David McLennan, “Beyond the Asylum: Professionalization and
the Mental Hygiene Movement in Canada, 1914-1928,” Canadian Bulletin of Medical
History/Bulletin canadien d’histoire de la médecine (CBMH/BCHM), 4 (1987): 7-23.
Statuts refondus du Québec (R.S.Q.), Ed. VII, 1909, Vol. II, chap. 4, “Lunatic Asylums.”
Alcée Tétreault, Cours des maladies mentales données à l’Hôpital Saint-Jean-de-Dieu, [s.l.],
[s.e.], around 1920, p. 61-63. [n.p.], [n.p.].
Tétreault, Cours des maladies mentales données à l’Hôpital Saint-Jean-de-Dieu, p. 86.
AHL-HL, Letter from Dr. Devlin to Dr. Desloges, 2 February 1921.
Notes historiques de l’Hôpital Saint-Jean-de-Dieu, internal publication, AHL-HL, 1923,
p. 12. The “permanent” psychiatrists in the early 1920s were doctors Devlin, Noël,
Tétreault, and de Bellefeuille. It was not until 1928 that the number of consulting
neuro-psychiatrists began to increase considerably.
The psychiatrists of Saint-Jean-de-Dieu were the doctors Devlin, Noël, de Bellefeuille,
Lahaise, Loignon as well as specialists, among them doctors Dufresne, Gagnier, and
Décarie. In addition there were consulting psychiatrists, among them doctors Plouffe,
Barbeau, Amyot, Saucier, Langlois, and Prévost. Omer Noël and Gaston de Bellefeuille, “L’Hôpital Saint-Jean-de-Dieu,” L’Union Médicale du Canada, 61, 2 (February
1932: 246-47.
Noël and de Bellefeuille, “L’Hôpital Saint-Jean-de-Dieu,” p. 254. Patients diagnosed
with pythiatism were those who simulated “hysterics.” Psychasthenics and neurasthenics were neurotics. The treatment of neuroses was a specialty of the Institut
Albert-Prévost; however, that institution was private and many did not have the
resources to be admitted there. As for “retarded” people, these are chronic cases of
“idiocy” and “imbecility.”
Paul-André Linteau, René Durocher, and Jean-Claude Robert, De la Confédération à la
Crise (1867-1929), Vol. 1 of Histoire du Québec contemporain (Montreal: Boréal, 1989),
p. 26; Paul-André Linteau, Histoire de Montréal depuis la Confédération (Montreal:
Boréal,1 992), p. 314.
Bruno Ramirez (coll. Yves Otis), La ruée vers le Sud. Migrations du Canada vers les ÉtatsUnis 1840-1930 (Montreal: Boréal, 2003) (translated from English by P. Lambert, Cornell University Press, 2001).
Linteau et al, Histoire du Québec, p. 470, 474, and Vol. 2, Le Québec depuis 1930 (Montreal: Boréal, 1989), p. 212, 277-81; Linteau, Histoire de Montréal, p. 314. The data have
been verified with websites of Statistiques Québec and the Census of Canada.
No data was available for the year 1931. The indicated number is an average between
the years 1930 and 1932 (1930: 4,165 patients, 1932: 4,192 patients).
Yves Vaillancourt, L’évolution des politiques sociales au Québec, 1940-1960, (Montreal:
Presses de l’Université de Montréal, 1988); Dennis Guest, Histoire de la sécurité sociale
au Canada, trans. H. Juste (Montreal: Boréal, 1993).
Marie-Claude Thifault, “Au-delà d’un rôle de protection à l’égard des aliénés: initiation
à l’art du nursing à l’Hôpital Saint-Jean-de-Dieu, 1912–1915,” in Sanni Yaya, ed., Pouvoir médical et santé totalitaire. Conséquences socio-anthropologiques et éthiques (Ste-Foy:
Presses de l’Université Laval, 2009), p. 341-58.
149
38 Annual report by Dr. Noël for the year 1931, Documents de la session parlementaire de la
Province de Québec, year 1931–1932, p. 31.
39 Bref historique de l’Hôpital Saint-Jean-de-Dieu, psychiatric hospital Louis-H.-Lafontaine,
1976 [1991 edition], 11 p.
40 Noël and de Bellefeuille, “L’Hôpital Saint-Jean-de-Dieu,” p. 246.
41 Annual report of Dr. Noël for the year 1932, Documents de la session parlementaire de la
Province de Québec, 1933, p. 110.
42 One hundred and forty-five recoveries for 2,358 patients in 1910, and 416 recoveries
for 5,428 patients in 1934. Data from the annual reports in the Documents de la Session
parlementaire, years 1911 and 1935, p. 22, 76.
43 As for the preceding years, the number of doctors include the psychiatrists Noël,
Richard, Loignon, Tellier, and Lahaise, as well as specialists and consulting psychiatrists. On the number of employees and sick, see Activités hospitalières des Sœurs de
Charité de la Providence (in Canada and in missionary countries) (Montreal: Providence Maison-Mère, 1937.
44 1er Rapport Annuel du Ministère de la Santé et du Bien-être social pour les années 1935 à
1941, Division des hôpitaux pour maladies mentales, Québec, 1944, p. 130. Of 12,786
patients confined, 1306 were on temporary leave. Saint-Jean-de-Dieu hospital had the
largesst population of people with mental illness, followed by St-Michel-Archange
hospital with 2792 patients et the Verdun hospital with 1037 patients, p. 128, 130.
45 Sister Louise of the Assumption, “L’Hôpital Saint Jean de Dieu : ses diverses activités,
son service social,” MA thesis, Université de Montréal, 1951, p. 53.
46 Sister Louise of the Assumption, “L’Hôpital Saint Jean de Dieu,” p. 53 47 He first presented this idea in 1931, and resumed it, more officially, in 1941.
48 C. A. Gauthier, “Un aspect négligé de l’hygiène mentale,” L’Union médicale du Canada
(August 1941): 851-52.
49 Gauthier, “Un aspect négligé de l’hygiène mentale,” p. 852.
50 R.S.Q., 1941, chap. 188, section 17.
51 Sister Louise of the Assumption, L’hôpital Saint-Jean-de-Dieu,” p. 2, 56.
52 Sister Louise of the Assumption, L’hôpital Saint-Jean-de-Dieu,” p. 2, 56.
53 R.S.Q. 1950, chap. 188, sections 8 and 12, “Loi des institutions pour malades mentaux.”
54 Jean-Marc Bordeleau, “Hôpital psychiatrique traditionnel et assistance psychiatrique
moderne,” Laval Médical, 41, 6 (June 1970): 751, 753.
55 We found that form in the files starting with the 1920s, as forms F, 9, and 11.
56 The total number of public patients accommodated in Saint-Jean-de-Dieu rose from
1,976 in 1910 to 2,953 in 1923 and to 4,777 in 1934. “In 1934, the hospital accommodated 4,777 public patients although it had a capacity of only 1,500 beds.” Courteau,
De Saint-Jean-de-Dieu à Louis-H.-Lafontaine, p. 94. Archives Providences. Statistics 1923
(SPM-M46_45.154_AG_Ae5_6); Dorvil et al., Défis de la reconfiguration des services de
santé mentale, p. 109; and Catherine Duprey, “La crise de l’enfermement asilaire au
Québec,” p. 140.
57 Form J: Request to temporarily keep an insane person on temporary leave.
58 Bernard Courteau made the same observation for the year 1906. He stated that half of
the patients put on temporary leaves remained outside. Courteau, De Saint-Jean-deDieu à Louis-H.-Lafontaine, p. 78.
59 Thifault, “L’enfermement asilaire des femmes au Québec,” p. 247.
60 AHL-HL. Correspondence medical file 8300, 24 June 1918.
61 Ellen Dwyer, Home for the Mad: Life Inside Two Nineteenth-Century Asylum (New
Brunswick and London: Rutgers University Press, 1987), p. 152.
62 AHL-HL. Correspondence, medical file 9544. 19 June 1910.
63 AHL-HL. Correspondence, medical file 15245. 20 August 1918.
64 AHL-HL. Correspondence, medical file 9252, 21 December 1911.
65 AHL-HL. Correspondence, medical file 10798, 27 January 1912.
150
66 See Joan Tronto, Moral Boundaries: A Political Argument for an Ethic of Care (New York:
Routledge, 1993).
67 Nancy Tomes, A Generous Confidence: Thomas Kirkbride and the Art of Asylum-Keeping,
1840–1883 (Cambridge: Cambridge University Press, 1984), p. 222.
68 Thifault, “L’enfermement asilaire des femmes au Québec,” Table 5. Population discharged from Saint-Jean-de-Dieu following a temporary leave, p. 251; statistics from
1960: Archives des Soeurs de la Providence de Montréal (ASPM), Annual Report from
1960, Table 1. General movement of mentally ill patients, p. 32.
69 AHL-HL. Correspondence, medical file 10763, 22 April 1912.
70 AHL-HL. Correspondence, medical file 4873, 3 November 1925.
71 AHL-HL. Correspondence, medical file 14369, 4 November 1915.
72 AHL-HL. Social enquiry, medical file 24131, 13 August 1940.
73 AHL-HL. Forms J, medical file 24131.
74 AHL-HL. Correspondence, medical file 10653, 26 August 1931.
75 AHL-HL. Correspondence, medical file 10677, 12 August 1927.
76 AHL-HL. Correspondence, medical file 10615, 13 October 1927.
77 Dorvil et al., Défis de la reconfiguration des services de santé mentale, p. 112.
78 André Cellard and Marie-Claude Thifault, Une toupie sur la tête, Visages de la folie à
Saint-Jean-de-Dieu (Montréal: Boréal, 2007); André Cellard and Marie-Claude Thifault, “The Uses of Asylums: Resistance, Asylum Propaganda, and Institutionalization
Strategies in Turn-of-the-Century Quebec,” in James E. Moran and David Wright,
eds., Mental Health and Canadian Society: Historical Perspectives (Kingston and Montreal: McGill-Queen’s University Press, 2006), p. 103.
79 ASPM. Register of temporary leaves from 1940 to 1950.
80 ASPM. Annual report, Saint-Jean-de Dieu Hospital 1960. Table 3. Comparative state of
the last four years, p. 34.
81 AHL-HL. Correspondence, medical file 8307, 10 November 1913; Form J: (discharge
“recovered”) 11 November 1913.
82 AHL-HL. Medical file 13933. Report in the file. Readmission in 1918 following a temporary leave obtained in 1913 and discharge with mention “recovered.”
83 AHL-HL. Correspondence, medical file 24122, letter from Dr. Noël addressed to the
lawyer of the patient on 28 October 1944.
84 AHL-HL. Correspondence, medical file 24122, letter from the lawyer to the patient,
2 November 1944.
85 AHL-HL. Correspondence, medical file 15714, 18 December 1922 and 20 December
1922.
86 The exploratory examination of the medical files of patients admitted in 1933, effected
with the valuable collaboration of Martin Desmeules, reveal this trend. This is an
avenue which our current research work will allow for better documentation.
87 Jacques LeGoff, “Jacques LeGoff ,” in Emmanuel Laurentin, ed., À quoi sert l’histoire
aujourd’hui? (Montrouge: Bayard Éditions and France Culture, 2010), p. 123-24.
88 Grenier, “Doctrine de la dégénérescence et institution asilaire au Québec (1885-1930),”
p. 34.
89 Dorvil et al., Défis de la reconfiguration des services de santé mentale, p. 120.
90 See Duprey, “La crise de l’enfermement asilaire au Québec,” p. 175.
91 Duprey, “La crise de l’enfermement asilaire au Québec,” p. 145-64.
92 Annual report from Dr. Villeneuve for 1906. Documents de la session, Vol. 41, no 2,
p. 199; Annual report from Madame la supérieure sœur Sabithe, for the year 1910; and
Documents de la session, Vol. 45, no. 3, 1912, p. 53.
93 Underlined by the author. AHL-HL. Correspondence from Dr. Villeneuve, 2 July
1913.

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